Appliance Breakdown Insurance Claim Form for Homeowners

Personal Details

Full Name Address Phone Number Email Address Policy Number

Appliance Information

Appliance Type Brand Model Number Serial Number Purchase Date Warranty Expiry Date (if known)

Breakdown Details

Date of Breakdown Description of Breakdown / Fault Action Already Taken (if any)

Repair / Replacement

Service Center Contacted Estimate / Invoice Number Repair/Replacement Cost

Additional Comments